8 Psychotherapy8.1 Psychodynamic psychotherapy
8.1.6 Adapted and integrative therapies
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Written by Resident Doctor Committee · Published
Cognitive analytic therapy
Origins
Anthony Ryle developed cognitive analytic therapy (CAT) within the NHS as a brief, time-limited integration of cognitive and analytic ideas.
Ryle drew on Vygotsky's zone of proximal development, the gap between what a patient can work out alone and what they can reach with a more skilled helper. Joint work is pitched within that gap.
Reciprocal role procedures
A reciprocal role procedure is a learned pair of linked roles from early relationships, such as caring and cared-for or controlling and controlled. It is the defining concept of CAT.
Either pole can be enacted towards others or towards oneself, so a criticising and criticised pattern may appear as self-criticism, criticism of others, or inviting criticism.
The patient re-enacts these roles with the therapist, who notices the pull to take the complementary role and uses it to map the pattern.
Countertransference is the therapist's own emotional reaction to the patient, traced to the therapist's own history. It runs from therapist to patient, whereas transference runs from patient to therapist.
Target problem procedures
Target problem procedures are recurring patterns of thought and behaviour that keep a difficulty going.
Procedure | Mechanism | Example |
|---|---|---|
Trap | A self-confirming loop: the behaviour brings consequences that confirm the negative belief behind it | Feeling unlikeable, placating everyone, being exploited, and concluding the belief was right |
Dilemma | A false either/or choice narrowed to two unsatisfactory extremes, with typical swinging between the poles | "Either I keep everything in or I explode" |
Snag | An appropriate, achievable aim is abandoned or sabotaged because it feels forbidden or undeserved, or because others are expected to object or be harmed | Giving up a promotion that would surpass a parent who never had the chance |
Dichotomous (all-or-nothing) thinking is a cognitive distortion in cognitive behavioural therapy (CBT) and is distinct from the CAT dilemma.
Structure of a course
CAT is delivered as a fixed contract within a range of 8 to 24 sessions.
A standard course is weekly over 16 to 24 sessions, and 24 is the upper limit, used for complex presentations such as borderline personality disorder.
The three Rs
The course moves through three phases in a fixed order.
Phase | What happens |
|---|---|
Reformulation (first) | Therapist and patient agree a written letter and a diagram mapping recurring relational patterns and reciprocal roles |
Recognition | The patient notices a pattern as it happens, in and out of sessions |
Revision | The patient tries an "exit", an alternative response |
Sequential diagrammatic reformulation is the flow-chart of reciprocal roles and procedural sequences, drawn jointly and usually complete by the sixth or seventh session.
Letters written by the therapist to the patient, the reformulation letter and goodbye letters, are specific to CAT.
Ending can reactivate relationship patterns, so it is planned explicitly. Goodbye letters review progress and remaining difficulties, and follow-up after several months is common.
Uses and contraindications
CAT is used in depression, anxiety and longstanding relational difficulties, including personality disorder and repeated self-harm.
Its evidence base is smaller than those for CBT and interpersonal therapy, and rests on many small studies.
CAT is generally contraindicated in acute psychosis, because collaborative reformulation needs intact reality testing and the capacity to reflect.
It is also contraindicated in severe depressive illness, dementia, delirium and acute suicide risk.
Mentalisation and mentalisation based therapy
Mentalising
Mentalising is reading behaviour, your own and others', in terms of mental states such as beliefs, wishes, feelings and intentions.
It fails under attachment stress, when intense arousal pushes thinking towards quick, concrete assumptions.
Development
A child learns to recognise and regulate feelings through marked, contingent mirroring: the caregiver reflects the infant's feeling promptly and accurately, showing that it belongs to the infant.
Loss of mentalising under stress follows disorganised attachment.
Modes of non-mentalising
Mode | What happens |
|---|---|
Psychic equivalence | A thought carries the force of fact ("I am disgusting") |
Pretend mode | Fluent, affectless talk about feelings changes nothing |
Teleological mode | A mental state counts only when something physical proves it, such as an admission or self-harm |
Mentalisation-based therapy
Mentalisation-based therapy (MBT), developed by Bateman and Fonagy, is a psychoanalytically rooted, manualised, attachment-based treatment for borderline personality disorder.
It aims to restore mentalising where attachment stress has disrupted it.
The therapist takes a curious "not knowing" stance, offers interpretations tentatively and slows down when arousal rises.
Therapy | Theoretical basis |
|---|---|
MBT | Attachment and mentalising |
Dialectical behaviour therapy (DBT) | Behavioural |
Transference-focused psychotherapy (TFP) | Object relations |
Evidence
Bateman and Fonagy's randomised trial allocated 44 patients with borderline personality disorder to MBT through partial hospitalisation or standard psychiatric care.
MBT was superior, with less self-harm, fewer suicide attempts and fewer admissions, and the gains lasted to eight-year follow-up.